Provider Demographics
NPI:1063991685
Name:REVIVE PAIN & SPINE CENTER INC
Entity type:Organization
Organization Name:REVIVE PAIN & SPINE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:AKBAR
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:530-650-8333
Mailing Address - Street 1:255 W COURT ST STE D
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-2986
Mailing Address - Country:US
Mailing Address - Phone:530-650-8333
Mailing Address - Fax:530-650-8388
Practice Address - Street 1:3609 MISSION AVE STE D
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-2955
Practice Address - Country:US
Practice Address - Phone:530-650-8333
Practice Address - Fax:530-650-8388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-14
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A134862081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1407843162OtherINDIVIDUAL NPI
CA1528383833OtherINDIVIDUAL NPI